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Under the RAC Microscope: Medical Necessity of Services - March, 2010
When it comes to recovery audit contractors (RACs), hospital leaders continue to ask: Where should we focus our time and attention? The answer is medical necessity-a key RAC target.
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Proposed 2010 Hospital OPPS Rule Issued: Many Changes Included, Some Welcomed - November, 2009
As you may know by now, the Centers for Medicare & Medicaid Services (CMS) have issued the proposed rules for 2010. One of the rules contains updated payment policy and rates for the hospital outpatient prospective payment system (OPPS) as well as ambulatory surgical centers (ASCs). The other rule updates the Medicare physician fee schedule (MPFS). Whatever elements of the proposed rules become final will take effect on January 1, 2010.
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New ICD-10-CM Coding System: CMS Sets Date for Implementation - July, 2009
Just six months after it issued a proposed rule for adopting the ICD-10-CM code sets, the U.S. Department of Health and Human Services (HHS) issued two final rules related to the topic. This is surely record time for the agency, indicating that its leaders are definitely listening to the likes of industry associations such as the American Hospital Association (AHA) and the American Health Information Management Association (AHIMA).
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2009 Coverage for Telehealth Technology: More Reimbursable Services and Eligible Sites - May, 2009
Radiology is among the medical specialties that most frequently use telehealth technology. The 2009 Medicare physician fee schedule (MPFS) adopts a couple of provisions of interest to those radiology practices now offering, or may offer in the offer, these services.
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BE PREPARED FOR MAC TRANSITION: Tips to Minimize Billing Disruption - March, 2009
By now, you've heard of Medicare administrative contractors (MACs)-firms that are taking over the responsibility of Medicare claims processing from fiscal intermediaries (FIs) and carriers. The Centers for Medicare & Medicaid Services (CMS) has already awarded MAC contracts to 10 of the country's 15 jurisdictions, and providers in many of these jurisdictions have claims systems up and running with their new MACs. For those providers who have yet to participate in the MAC program, the CMS recently issued instructions to help smooth the transition.
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More Bundled Medicare Payments Ahead: ACE Demonstration Tests Concept for Acute Care - September, 2008
With the recent announcement of the Acute Care Episode (ACE) Demonstration, the Centers for Medicare & Medicaid Services (CMS) sent a signal to the industry that it intends to head in the direction of bundled payments for inpatient physician and hospital services, at least for select procedures. The ACE Demonstration will test whether the new payment structure results in cost efficiencies and quality improvements for Medicare and its beneficiaries.
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Physician Signatures on Test Requisitions: CMS Clarifies Medicare Policy - July, 2008
Has your laboratory received documentation requests from the comprehensive error rate testing (CERT) contractor (AdvanceMed) asking for an original requisition signed by the ordering physician? If so, you're not alone. According to a letter from the American Clinical Laboratory Association (ACLA) to the Centers for Medicare & Medicaid Services (CMS) in mid-March, many laboratories have received such requests. What's more they received notification that the testing is inappropriate, and the claim will be denied if no such requisition can be produced. (Don't panic! It's not true.)
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Codes Subject to CLIA Edits in 2008: CMS Issues a List of Eight Codes - July, 2008
As you probably know, the CPT codes that CMS considers to be laboratory tests under CLIA, which require a certification, change each year. In Transmittal 1471 (February 29), CMS informed Medicare carriers and Part A/B Medicare administrative contractors (MACS) about the 2008 codes that are subject to CLIA edits and also about those that are now excluded from CLIA edits.
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Billing Emend® Tri-Pak on Outpatient Claims: Clarifications Issued on Wrongful Denials - May, 2008
It has come to the attention of the Centers for Medicare & Medicaid Services (CMS) that payment denials are occurring for the three-drug combination of oral anti-emetics contained in the Emend Tri-Pak because two doses of anti-emetics are sent home with the patient. The denial of these claims resulted from a misinterpretation by the Medicare fiscal intermediaries (FIs) of a policy concerning the billing of take-home drugs.
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Ordering Diagnostic Tests in Non-Hospital Settings: CMS Discovers and Issues Missing Guidelines - March, 2008
Although it's been several years since the Centers for Medicare & Medicaid Services (CMS) transitioned from the Medicare Carriers Manual (MCM) to the Internet-only manual, it has just gotten around to incorporating language it says it "inadvertently omitted" related to the requirements for ordering, and following orders for, diagnostic tests in non-hospital settings.
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Final 2008 Hospital OPPS Rules Issued: Details for Pharmacy Departments Abound - January, 2008
The 2008 interim and final rule with comment period for the Medicare hospital outpatient prospective payment system (OPPS) weighs in at 1,969 pages! As you might imagine, it is chock full of changes to implement new statutory requirements and refine various parts of the payment system. All changes, unless otherwise noted, take effect on January 1, 2008.
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Laboratory and Pathology Claims: Top Denial Reasons from Trailblazer - January, 2008
Duplicate claims' submissions are the number one reason for denials or rejections of laboratory and pathology claims, according to Trailblazer Health Enterprises, a Medicare contractor.
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2008 MPFS Final Rule Highlights Lab Changes: DOS for TC of Pathology and Reconsideration Process - December, 2007
The 2008 final Medicare physician fee schedule (MPFS) includes two sections related to the clinical laboratory fee schedule. More details about the new policies can be found in the MFPS sections noted.
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Reconstruction of Computed Tomography: ACR Issues New Opinion on Initial Data Studies - November, 2007
The American College of Radiology (ACR) recently published information about the reconstruction of computed tomography (CT) studies from initial data. Its previous opinion and new opinion are provided below. A follow-up question from MedLearn to the ACR is also provided as well as a response to it from an association representative. A brief analysis by one of the situation caused by the new ACR opinion concludes this article.
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Diagnostic Radiology Claims: Most Common Reasons for Denials - Learning from the Mistakes of Others - October, 2007
Medicare contractor Trailblazer Health Enterprises recently issued a list of its top reasons for denying or rejecting diagnostic radiology claims between March and June 2007. Even if it isn't your payer, you may want to review this information with an eye toward your own history of denials, and take steps to ensure that you reduce them.
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Assignment of Code 35495: Clarifying the Confusion of When to Report - September, 2007
Even though the definition of surgical code 35495 is different from code 35470, they should be used in the same fashion (i.e., per vessel treated). That's the easy answer to a conundrum that has confused even the best of coders. In large part, the confusion can be traced back to the fact that the differences between these two code descriptions (shown below) are subtle even though they do define the same anatomic areas.
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CMS Gets Tough on Security: Outlines Rules for Eligibility Inquiries - July, 2007
Anyone performing eligibility inquiries for radiology should be familiar with these rules.
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Common Laboratory Medicare Billing Errors: Avoid These on Claims Submitted to Carriers - July, 2007
One goal of coding and billing management for laboratory procedures is, of course, to submit accurate claims so they will not be denied, rejected, or delayed because of incorrect or incomplete information. The Centers for Medicare & Medicaid Services (CMS) recently issued an article that includes the most frequent errors found in claims submitted to Medicare carriers. Listed below are errors and some tips to avoid them.
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New Edit for the TC of Radiology Services: Physicians May Not Bill for Hospital Inpatients - May, 2007
The Centers for Medicare & Medicaid Services (CMS) announced that it would install a common working file (CMF) edit to prevent Medicare carriers from paying for the technical component (TC) of a radiology service provided during an inpatient stay. CMS announced the new edit, which will take effect on April 1, 2007, in Transmittal 1098 (Change Request 5347), November 2, 2006.
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2007 Fee Schedule Payments for New and Revised Lab Codes - April, 2007
Only two of the 15 codes that the American Medical Association added and revised in the 2007 CPT coding system are not paid under the fee schedule. Both of these are cytopathology codes-88106 and 88107, which will be paid under the hospital outpatient prospective payment system. The rate for each is $15.72.
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